The MomsTEAM staff and I are still digging into the Institute of Medicine and National Research Council's three-hundred-some-odd page report on sports-related concussions in youth sports,^[1]  but one thing jumped out at me at my first pass: When I did a search in the report for a discussion of impact monitoring devices (a/k/a hit sensors), I found only one brief mention of sensors in the committee's recommendation that the Centers for Disease Control fund large scale data collection efforts for research purposes, including data from impact sensors.

Conspicuous by its absence from the report was any mention of the practical applications for such technology, especially but not limited to helping to identify athletes who may have suffered a concussion so they can be evaluated for possible concussion on the sports sideline.

I know firsthand from working with high school football players while producing "The Smartest Team," that impact sensors hold enormous promise, most significantly as a technological 'end around' the "culture of resistance" to self-reporting concussion symptoms, which the IOM/NRC report correctly recognizes as perhaps the single biggest obstacle to improving concussion safety in contact and collision sports.

But I found the omission especially glaring and surprising given that a number of leading concussion researchers, including the University of Michigan and Michigan Neurosport's Jeffrey Kutcher ^[2] and Steve Broglio, ^[3] have both written recently about the benefits of real time impact monitoring, not just for research, where they have been used in gathering biomechanical data for about a decade, but on the sports sideline.

Writing about head impact sensors in a study about emerging technologies in concussion identification and management in the March 2013 issue of the British Journal of Sports Medicine,^[2] Dr. Kutcher, a neurologist specializing in the treatment of sports-related concussions and the co-author of the updated, evidence-based concussion management guidelines issued by the American Academy of Neurology,^[4] viewed the "development of easily deployable sport equipment-based accelerometer systems" as "providing potentially useful, clinical information"  in at least two ways.  

First, Kutcher said, impact sensors have utility in monitoring impacts during the course of an athletic event for the purpose of screening for potential injury.  While acknowledging that " an on-board accelerometer system may not be able to accurately predict injury," Kutcher said, "it may have utility as a screening device by alerting sideline personnel of an impact that has occurred above a predetermined magnitude that triggers either observation or clinical evaluation of an athlete."

Second, Kutcher also saw a potential clinical benefit for real time impact monitoring systems, one which "stems not from the idea of monitoring impacts for the presence of an acute injury-generating hit, but from the potential advantage of accurately cataloguing the number of hits and post-impact head acceleration being experienced by an athlete over time."

"Some have suggested that the idea of a 'hit count' that is kept for athletes over the course of a game, practice, week, month, season or career," he writes.  Kutcher recognized that the "concept is fairly new and, as yet does not have published data to suggest that any particular level or number of hits has significant clinical meaning for any particular sport or position."  On this point, the IOM/NRC report essentially agreed, stating that "implementing a specific threshold for the number of impacts or the magnitude of impacts per week or per season was without scientific basis."  Nonetheless, he said that "individual athletes may feel there is a benefit to having an estimate of forces their brain experiences over time."

For his part, Dr. Broglio is also on record as seeing merit in the use of impact sensors in facilitating the identification of concussed athletes. While he acknowledged, as do I, that sensors are currently beyond the reach of most football programs, he, like I, saw a day in the not too distant future when use of such instrumentation would be "both practical and feasible."

In case you don't know about Steve, he is, along with Kevin Guskiewicz at the University of North Carolina, and Steve Rowson and Stephan Dumas at Virginia Tech, one of the leading experts on the use of accelerometers in football helmets in biomechanical studies, so he knows whereof he speaks (or to paraphrase the old John Houseman ad for Smith Barney, When Broglio talks, people should listen.)

Teaching tool 

Speaking of Guskiewicz, in a recent article on SI.com  he pointed to a third practical use for impact sensors outside of the research arena: to help coaches and other personnel identify athletes who are sustaining a high number of high force impacts, especially to the top front of their helmets that appear to be the most worrisome from a brain trauma standpoint, as a result of poor tackling or blocking technique.

Since emerging research suggests that repetitive subconcussive impacts may actually have more of a deleterious long-term effect on the brain than those blows that result in concussion, why didn't the IOM/NRC report recommend use of data from impact sensors by football coaches to reduce total brain trauma by modifying behavior, as Guskiewicz has been doing at UNC for years? "If a player is observed repeatedly sustaining larger impacts to the crown of his head," he told SI, "coaches will work with him on adjusting his technique." 

Using impact sensors as a teaching tool isn't just happening at the college level. It is happening in high school football, too. After Purdue researchers^[5] found that high school football linemen who sustained a high number of high impact sub-concussive hits over the course of a season were the ones suffering impairment of their visual memory, the information led at least one player to change his blocking technique.

As Tom Talavage, the lead author of the Purdue study, told Frontline in a 2011 interview, he thought at least 50 percent of the high impact hits linemen and linebackers were sustaining were due to poor technique.  "Some of the players that we have on our team have not very good technique, to be quite honest. And what you'll find is, they will launch into a play, and they will lead with their helmet. Other players will more correctly keep their head up, try to get their arms up as a blocking technique, or when they're rushing, they will try to get their arms up as a means to push the offensive lineman out of the way. Those technique differences lead to a very large difference in the total number of blows experienced and where those blows are experienced on the head."

Talavage said that when one of the offensive lineman who was found to have been functionally impaired after sustaining a high number of subconcussive blows, impairment that persisted beyond the season, decided to change his technique, he experienced a drastic reduction in the number of blows he experienced to the top front of his head and a moderate reduction in the total number of blows. 

The result was that, after the second season, "his neurocognitive testing never detected any deficits, and from an imaging perspective we saw substantially less change in his fMRI activity. There's still some, because he's still getting hit, but his technique changed the distribution."

Research suggests that the cumulative effect of subconcussive impacts increases the risk of long-term neurodegenerative diseases such as CTE, PD, AD, MCI and ALS. While researchers continue to look for the concussion "holy grail" in the form of specific impact thresholds above which concussions are highly likely and/or the number of impacts or the magnitude of impacts per week or per season that substantially increase the risk of long term brain injury, why not use technology available right now to do what we can to reduce total brain trauma by using impact data to identify kids who need more coaching so they can learn how to tackle and block without using their helmets?

Red herrings

Given what so many respected scientists are saying about the use of impact sensors, why, again, is there no mention in the IOM/NRC report of any of these uses?

Was it because the committee was under the impression that the impact sensor systems that have come on the market in recent years are intended to diagnose concussions.  Was it out of concern that equipping players with sensors would provide a false sense of security and foster a belief that if the sensor didn't go off, the player didn't suffer a concussion?

The fact is that sensors are not intended to be diagnostic, or to replace sideline observers, game officials, coaches, and teammates, who, if they observe an athlete exhibiting signs of concussion, can trigger a sideline screening for concussion using one or more assessment tools (eg. SCAT3, King-Devick,  Maddocks questions). They are simply intended to be another tool in the concussion toolbox or, put another way, another set of eyes. Like those assessment tools, the fact that a sensor triggers an alert - or fails to set off an alert - is not intended to rule an athlete in or out of action or in any way diagnose concussion

The biggest challenge, of course, to widespread deployment of sensors now is their cost. The NFL and college football programs may be able to afford the technology, but coming up with the money to equip teams at the youth and high school level will require creative funding solutions, at least until the cost per player comes down, as it inevitably will over time.

The Institute of Medicine and National Research Council could have given impact sensors a big boost had the report at least discussed their use.  Unfortunately, the lack of any such discussion will just end up making it that much more difficult to get the message out about the benefits of real-time impact monitoring, and places an additional obstacle in the path to their use.

It was a barrier that they simply didn't need to raise.  

1. Institute of Medicine (IOM) and National Research Council (NRC). 2013.Sports-related concussions in youth: Improving the science, changing the culture. Washington, DC: The National Academies Press.

2. Kutcher J, McCrory, Davis G, et al. What evidence exists for new strategies or technologies in the diagnosis of sports concussion and assessment of recovery?Br J Sports Med2013;47:299-303.

3. Broglio SP, Martini D, Kasper L, Eckner JT, Kutcher JS.  Estimation of Head Impact Exposure in High School Football: Implications for Regulating Contact Practices. Am J Sports Med2013;20(10). DOI:10.1177/036354651302458 (epub September 3, 2013). 

4. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurologists. Neurology 2013;DOI:10.1212/WNL.0b013e31828d57dd (published online ahead of print March 18, 2013).

5. Talavage TM, Nauman E, Breedlove EL, et al. Functionally-detected cognitive impairment in high school football players without clinically diagnosed concussion.J Neurotrauma. 2013;doi:10.1089/neu.2010.1512 (e-publ April 11, 2013)

Brooke de Lench is Founder and Publisher of MomsTEAM.com, author of Home Team Advantage: The Critical Role of Mothers in Youth Sports, and the producer/director of the PBS documentary, "The Smartest Team: Making High School Football Safer."  

On Monday, I was able to catch up with three-time Olympic medalist Julie Chu, member of the U.S. Women's National Ice Hockey team, who just happens to be living and training for the XXII Olympic Winter Games in Sochi, Russia in my neck of the woods outside Boston.

I decided it was a great time to ask her to reflect back on her hockey journey over the past twelve years, and to hear about how she and her team are preparing for the challenge of replacing the Canadian women atop the podium this time around.

I was thrilled to learn that Julie is being supported in her fourth quest for that elusive gold medal by one of MomsTEAM's favorite companies, Procter & Gamble, makers of Bounty paper towels, "The Family of Picker Uppers." (Sounds like all of us moms, right? Picking up kids, from practices, games, school, and the mall, not to mention their equipment; and, of course, cleaning up their messes! The things we do for love!) 

It seemed like a natural for Bounty to be teaming up with Julie and her mom, Miriam, in celebrating all the moms who are only too happy to clean up after their kids' messes around the house if it means they can spend a little more time training in order to unlock their full potential as athletes.  In the spirit of the Olympics, I say, "Let the spills begin!"

More on Bounty and how moms can get involved in a minute, but first, a little bit of history and more about what Julie is thinking as she prepares for the Olympics.  I have been following Julie's career ever since we first met in Lake Placid in 2002, where she was training for her first Olympics in Salt Lake City.  At nineteen, she was one of the youngest, if not the youngest players on the team.

I had made the trip to Lake Placid to interview a number of athletes who were practicing and/or trying out for various teams.  Over dinner with Julie and Angela Ruggiero, who was keeping a journal of her journey to Salt Lake for MomsTEAM at the time, I got to know Julie; about her work ethic, interesting upbringing, supportive family (especially her amazing mom), and her passion for ice hockey. Later, while I was hanging out at the Olympics in the AT&T Friends and Family Center, I also had a chance to get to know her mom, Miriam Chu, as well. It was no wonder to me that Miriam raised an Olympic athlete.

Missing ingredients? 

During our conversation, I asked Julie about the new coach of the Women's National Team, Katey Stone, one of the most successful coaches in the history of Division I women's ice hockey as the longtime head coach of the Harvard Crimson. Julie had nothing but good things to say about her former college coach, the first woman to lead the U.S. women since hockey became an Olympic sport in 1998. We agreed that she might just be what the team needed to break the Canadian women's hold on the gold medal, and bring the Olympic title back to America for the first time since the U.S. struck gold at the Nagano Olympics in 1998.

When I asked Julie what she has been doing differently this time around to prepare for Sochi, she said that the biggest difference was that she and her teammates "have been committed to their off-ice conditioning and have been more accountable to what they are doing to train during their non-Olympic years. This is just important as time on the ice."  I knew how fortunate they are strength and conditioning coach Mike Boyle, who has worked with many elite athletes, in their corner! (Here's a video of Mike talking with Julie's former teammate, Angela Ruggiero)

Special memory

When I asked Julie about her plans for the future after the Olympics, she gave me a really great answer: "I am only focusing on the Olympics right now. I can think about my future after the Olympics. We will be there to win, and we will all have some time to have fun while in Sochi, but our main goal is to win the gold."

I think that Julie's perspective is a great one to share with kids: focus on your goals, but make sure you have fun along the way. For me, I always tell my sons that if they focus on the summit they are trying to reach, and not get too distracted from that goal, their path will be clear.

Julie will always hold a special place in my heart, along with the entire 2002 Women's Hockey Team, for surprising me with a cake and, along with my triplet sons, serenading me with "Happy Birthday" on the day I turned 50 at the Olympics in Salt Lake City. It has been a pleasure following Julie and many of her teammates, including Caitlin Cahow and Angela, these past twelve years. To watch how they have progressed in their sport has been a phenomenal experience. (Here's a picture of Caitlin, Angela, and Julie I took at Fenway Park before the 2010 Winter Classic)

Bring it on, moms! 

Given all the thrills they have given me, it seems as if the least I can do in return is to support Julie and Bounty in their search for moms across the country who know that, sometimes when you have healthy, active kids, things can get a little messy!

Whether your kids are doing cartwheels down the hall or firing a slap shot into the fireplace, Bounty is saluting moms who don't sweat the mess!

So, from now until the 2014 Sochi Winter Olympics, sports moms everywhere can log on to Twitter and share with @Bounty stories about how they have helped their aspiring athletes to train in the home despite the mess.

For every story shared with @Bounty using the #BringIt hashtag, Bounty will donate $1.00 to the P & G Team USA Youth Sports Fund to help other athletes pursue their Olympic dreams.

Moms can also join the Bring It conversation and stay up-to-date on Julie's journey to Sochi by visiting Facebook.com/Bounty or Twitter.com/Bounty.

Bring on the world! 

To get ready for the Games, the U.S. Women's National Team will be traveling around the country, participating in the Bring On the World Tour. For complete information on the Tour, including ticket information for Tour events and the entire game schedule, click here. 

The final roster for the 2014 U.S. Olympic Women's Ice Hockey Team, which will include 18 forwards/defensemen and three goaltenders, will be announced during the second intermission of the NHL Winter Classic on January 2014 in Ann Arbor, Michigan, live on NBC.

Follow the U.S. Women's National Team throughout its journey to Sochi @USAHockey on Twitter or by liking the U.S. Women's National Hockey Team's page on Facebook.

It has been a good two weeks for parents looking to make high school football safer, with a number of promising developments. But it is not time to declare victory, and many questions remain to be answered.

More Lystedt laws 

First, on the legislative front, three more states (Tennessee, Georgia and Montana) enacted Lystedt concussion safety laws, bringing to 45* (plus the District of Columbia) the number now requiring that schools (and, in some cases, as with Georgia, independent youth sports organizations using public fields):  

1. educate youth athletes and their parents, and, in some cases, coaches, about the signs and symptoms of concussions, the dangers of continuing to play with concussion, and acknowledge receipt of a concussion information form as a condition for playing sports;​​
2. remove from play any youth athlete suspected of having suffered a concussion and not allow them return to play that day; and​​​​
3. require written clearance from a licensed health care professional trained in the evaluation and management of concussions before an athlete can return to play.

Two more states (South Carolina and West Virginia) are moving towards passage of Lystedt laws.  [Update: Both states have since enacted Lystedt laws, bringing the number of states with such laws to 47, plus D.C.]

What about the remaining three states (Arkansas, Wyoming and Mississippi)?

In the case of Arkansas, its legislature recently appropriated $1 million for a pilot concussion management project, and, under guidelines issued by the Arkansas Activities Association, the state's governing body for high school sports, student-athletes suspected of having suffered a concussion must be removed from play immediately, cannot return to play within 24 hours after concussion, and only then after obtaining a written release from a medical professional current in concussion management clearing the athlete to begin a mandatory 5-day graduated return to play protocol. 

Wyoming's youth sports concussion safety law (Chapter 190), signed into law in March 2011, requires the state Superintendent of Public Instruction to develop a model protocol and to assist school districts in developing protocols for addressing risks associated with concussions and other head injuries from school athletics, and that school districts adopt protocols to address risks associate with concussion and other head injuries, including providing training to coaches and trainers, restricting a student's participation in sports after suffering a concussion or head injury, and distributing educational information to students and parents, but does not, among other things, require removal of athletes from games or practices if they are suspected to have suffered a concussion, or require medical clearance before return to play.

That leaves Mississippi as the only state in the country without any legislation or athletic association rule on concussion safety, enacted or pending. 

Effectiveness of laws remains to be seen 

For the past month I have been trying without success to find the time to join the makers of the new documentary, "Crash Reel," at one of their premiere screenings. It is a movie I have been very eager to see for a number of reasons. Finally, over the weekend, I was able watch the film, which airs tonight on HBO at 9:00 p.m. EDT.

I am so glad I finally was able to see the film.  Not only did it exceed all of my expectations, but, it evoked in me a mix of both wonderful and sad memories from my past.

The film is chock full of very powerful life lessons, many that I think will be obvious ones parents will want to share with children, but many they don't even know they need to share.

For those of you who don't already know about the movie, "Crash Reel" is about former professional snowboarder Kevin Pearce and his inspiring recovery from a severe, life-threatening traumatic brain injury (TBI) sustained in a crash before the 2010 Vancouver Olympics.

On one level, it is a straightforward tale about how, working with a team of medical and psychological caregivers, Pearce has been able to recover from his injuries.

But "Crash Reel" is about so much more.

It is about the risks too many young athletes feel they have to take to succeed in their sport.

It is a film about the importance of family and having faith in each other, and how each can play a pivotal role in the journeys of the others, in both sickness and in health.

It is about what we can learn from people we might be tempted to think are the ones least likely to be in a position to give sage advice: in this case, one of Kevin's three brothers, David, who was born with Down Syndrome. It made me wish that David had been around to help my family after one of my sons suffered a bad concussion while snowboarding.

I remember when Kevin was injured during a training run while preparing for the Olympic qualifying trials just weeks before the 2010 Olympics, when he caught an edge and slammed face first on the halfpipe structure while attempting to do a "double cork," a twisting double back flip trick. I recall listening to the morning news the day after his accident with disbelief and profound sadness.

I had been rooting for Kevin since he beat the supposedly "unbeatable" phenomenon Shaun White, and was hoping to see him standing on the podium in Vancouver, perhaps standing on a step above his onetime close friend, Shaun.

As some of you know from my previous blogs, I have always been a huge Winter Olympics fan, no doubt due to the fact that my dad lived on Stratton Mountain in Vermont, where I grew up as a "mountain rat."

I was at Stratton when my step-brother and Jake Burton Carpenter and their friends developed the first snowboards in the 1970s and watched as they rocketed down the mountain at breakneck speeds and launched for what were, at the time, heart stopping jumps off of four-foot ramps.

When I made plans to to attend the 2010 Olympics, I purchased tickets early to make sure that I was there to watch the snowboarding events and the halfpipe finals, just as I had done for the men's and women's finals of the Snowboarding GS at Park City, Utah during the 2002 Winter Olympics.

Snowboarding is one of my favorite Olympic sports to watch and my friends and I were sure Kevin would be on the podium.

The flip that Kevin was trying when he was injured had not yet been mastered. It was one that many of the men who would be competing at the Olympic trials were trying to add to their routines. His fall, like so many catastrophic falls or crashes, did not look to be as horrific as it turned out to be. (Dale Earnhardt's fatal crash at the Daytona 500 a few years back comes to mind)  Sadly, some of the falls that look like the athlete will jump to their feet end up killing or severely injuring them.

As someone who has been covering the sport-related concussion beat for the past 13 years, I wondered at the time whether Kevin was still recovering from a previous head injury days or weeks that made his injury worse. I have since learned that indeed he may have had a concussion just three weeks prior. That injury, coupled with the mental and physical pressure he was under in his attempt to beat Shaun White and others may have made a bad situation even worse. We now know that when athletes are tired they are more prone to accidents.

The valuable lesson from "Crash Reel" for parents is to never assume one head injury has healed before letting your child resume a sports activity. Many times we see a snow sport athlete take a hit to the head or body that creates a whiplash effect, and don't think much of it until we learn they indeed have been severely injured. This lesson was brought home to me after film star Natasha Richardson fell during a ski lesson ten months before Kevin's accident and ended up dying a short time later from a brain bleed. It was also brought home when professional freestyle skier Sarah Burke took a fall on the same half pipe at Park City, Utah on which Kevin was injured.

Perhaps one of the most thought provoking statements for parents in the movie came from Kevin's father toward the end of the film:

"After the accident I felt very responsible, it was all the money involved, in all the sponsorships, it wasn't just Kevin. There should be limits I think just like there is in car racing. Finally they had to limit the sizes of the engines in the racing cars because people were killing themselves. It's the same in many halfpipes. If you make the rails higher, which makes it more dramatic for the spectators and the television and the media, the athlete will go, I mean he will push it to the limits. It's in the athletes make-up. I felt at some level we were all to blame."

These are tough issues I work with every day, mostly with football parents.

We finish watching "Crash Reel" knowing that Kevin and his family have emerged from his near tragedy stronger than ever. We hear him talking with snowboarder Trevor Rhoda, who has sustained two TBIs and now has a serious brain injury, in the aftermath of which he has been mean to his mom.

Kevin tells Trevor that, "Being mean to them [moms] is not helping." And, as he leaves Trevor and walks down a long path with his own mom, Kevin tells her, "This has changed my life. Now I can help change other people's lives." And we know that Kevin will do just that, and that "Crash Reel" and his advocacy on traumatic brain injury will have a great impact on the young athletes of this country..

The only thing that I wish had been included in the movie was a scene showing all of the people who were at Cascade Mountain the day two Americans placed in the top three at the finals during the Olympics. Shaun White won the gold and Scotty Lago won the bronze. To his credit, White absolutely nailed his first run; we all know that things didn't end so well for Lago, who was sent home early.

What I wanted the viewers to see was all of the signs people were holding that read, "I Ride For Kevin." Each of us standing along the run that day were thinking of Kevin as he lay in a hospital bed.

As we all begin to gear up to purchase tickets to Sochi for the next Olympics in February of 2014, I wonder how all of the top USA hopefuls are doing practicing at the Mount Hood superpipe. The height of the walls has now been capped at 22 feet. For me, I won't be watching any more snowboard events until, for safety's sake, the rails are lowered just a bit, maybe not all the way back to the four feet that I once thought was too high, but low enough to reduce the risk of injury of the kind that Kevin suffered in attempting a move that simply pushed the envelope too far and involved too much risk.

If you do nothing else with your kids this summer I suggest you watch "Crash Reel" with them, and, if you add it to your DVR or TIVO queue, I bet they will watch it over and over with their friends.

For years, it seems, MomsTEAM has been getting e-mails from mouth guard manufacturers touting their products as reducing the risk of concussion, despite the lack of any peer-reviewed scientific studies to support their claims. 

Last year, as readers of my blog may recall, I even got into a bit of a tete-a-tete with the co-author of one of the many books about concussions that have come out in recent years, when, at the end of an otherwise favorable review of the book, I took the authors to task for including a story about how one college athlete with a multiple concussion history was allowed to take the basketball court (after switching schools) because she agreed to wear a "customized mouthguard designed for greater shock absorption."  I believed then - and continue to believe -  that the story sent the wrong message: that mouthguards can prevent concussions.

So it was with a certain degree of satisfaction that I read yesterday of an announcement by the Federal Trade Commission that it had reached a settlement barring Brain-Pad, a mouthguard manufacturer, and its President, Joseph Manzo, from making unsupported claims that its mouthguard reduced the risk of concussion from lower jaw impacts, reduced the risk of concussions generally, or have been clinically proven to do either. 

In announcing the settlement, the FTC's Director of the Bureau of Consumer Protection, noted that, "Mouthguards can help to shield a person's teeth from being injured, and some can reduce impact to the lower jaw.  But it's a big leap to say these devices can also reduce the risk of concussion. The scientific evidence to make that claim just isn't adequate."

The action by the FTC was immediately applauded by Senators Tom Udall (D-N.M.), who has been outspoken in recent years on the subject of concussion safety.  Udall told the Hill newspaper that, while "increased awareness of the dangers associated with sports concussions is extremely important, as the Brain-Pad settlement proves, some companies seem to be taking advantage of the fears of parents, coaches, and athletes." 

MomsTEAM has been reminding parents for years that mouth guards should be worn to protect against dental injuries, not because they reduce concussion risk.  It is reassuring that the FTC, the government agency charged, among other things, with evaluating health claims by advertisers to make sure they are supported by the evidence, is doing its job, too.

For my earlier blog on the mouth guard/concussion controversy, click here.